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Patient Assistance Information

 
 
 
Torisel Reimbursement Support and Patient Assistance Program

PO Box 220907
Charlotte, NC 28222
Phone : 866-993-8466
Fax: 866-993-8411
Eligibility
> The patient must have no prescription coverage for the requested medication and meet income guidelines that are not disclosed. The patient must also be under treatment from a US doctor.
Who Can Apply
> The doctor/doctor's office should call for an application.
Required
> The doctor must fill out a section and sign the application.The patient must fill out a section of the enrollment form and sign it.
Supply
>
Ship To
> Doctor's office
Note
> The doctor/doctor's office should call for an application.
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Mylotarg
Neumega
Torisel Injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader